mrandmissregalnigeria.pages.dev
Open in
urlscan Pro
172.66.44.246
Public Scan
URL:
https://mrandmissregalnigeria.pages.dev/form/
Submission Tags: @ecarlesi possiblethreat phishing Search All
Submission: On July 06 via api from IT — Scanned from IT
Submission Tags: @ecarlesi possiblethreat phishing Search All
Submission: On July 06 via api from IT — Scanned from IT
Form analysis 2 forms found in the DOM
POST
<form id="regForm" action="" method="post" enctype="multipart/form-data">
<input type="hidden" name="action" value="addRegForm">
<input type="hidden" name="party3rd" value="<?php echo $party3rd;?>">
<div style="text-align:left" class="col-md-8 col-md-offset-2">
<div class="row">
<div class="col-md-6">
<b>First Name <font color="red">*</font></b><br>
<div class="input-group">
<input name="first_name" type="text" id="first_name" value="" class="form-control" placeholder="First Name" required="">
<span class="input-group-addon"><i class="fa fa-user"></i></span>
</div>
</div>
<div class="col-md-6">
<b>Last Name <font color="red">*</font></b><br>
<div class="input-group">
<input name="last_name" type="text" id="last_name" value="" class="form-control" placeholder="Last Name" required="">
<span class="input-group-addon"><i class="fa fa-user"></i></span>
</div>
</div>
</div>
<br>
<div class="row">
<div class="col-md-6">
<b>Email <font color="red">*</font></b><br>
<div class="input-group">
<input name="email" type="email" id="email" value="" class="form-control" placeholder="Email Address" required="">
<span class="input-group-addon"><i class="fa fa-envelope"></i></span>
</div>
</div>
<div class="col-md-6">
<b>Phone Number <font color="red">*</font></b><br>
<select id="select-country" name="phone_code" class="form-control" style="width: 25%;position: absolute;z-index: 5;">
<option value="93">(+93) - Afghanistan</option>
<option value="355">(+355) - Albania</option>
<option value="213">(+213) - Algeria</option>
<option value="1684">(+1-684) - American Samoa</option>
<option value="376">(+376) - Andorra</option>
<option value="244">(+244) - Angola</option>
<option value="1264">(+1-264) - Anguilla</option>
<option value="672">(+672) - Antarctica</option>
<option value="1268">(+1-268) - Antigua And Barbuda</option>
<option value="54">(+54) - Argentina</option>
<option value="374">(+374) - Armenia</option>
<option value="297">(+297) - Aruba</option>
<option value="247">(+247) - Ascension Island</option>
<option value="61">(+61) - Australia</option>
<option value="43">(+43) - Austria</option>
<option value="994">(+994) - Azerbaijan</option>
<option value="1242">(+1-242) - Bahamas</option>
<option value="973">(+973) - Bahrain</option>
<option value="880">(+880) - Bangladesh</option>
<option value="1246">(+1-246) - Barbados</option>
<option value="375">(+375) - Belarus</option>
<option value="32">(+32) - Belgium</option>
<option value="501">(+501) - Belize</option>
<option value="229">(+229) - Benin</option>
<option value="1441">(+1-441) - Bermuda</option>
<option value="975">(+975) - Bhutan</option>
<option value="591">(+591) - Bolivia, Plurinational State Of</option>
<option value="599">(+599) - Bonaire, Saint Eustatius And Saba</option>
<option value="387">(+387) - Bosnia & Herzegovina</option>
<option value="267">(+267) - Botswana</option>
<option value="55">(+55) - Brazil</option>
<option value="246">(+246) - British Indian Ocean Territory</option>
<option value="673">(+673) - Brunei Darussalam</option>
<option value="359">(+359) - Bulgaria</option>
<option value="226">(+226) - Burkina Faso</option>
<option value="257">(+257) - Burundi</option>
<option value="855">(+855) - Cambodia</option>
<option value="237">(+237) - Cameroon</option>
<option value="1">(+1) - Canada</option>
<option value="238">(+238) - Cape Verde</option>
<option value="1345">(+1-345) - Cayman Islands</option>
<option value="236">(+236) - Central African Republic</option>
<option value="235">(+235) - Chad</option>
<option value="56">(+56) - Chile</option>
<option value="86">(+86) - China</option>
<option value="61">(+61) - Christmas Island</option>
<option value="61">(+61) - Cocos (Keeling) Islands</option>
<option value="57">(+57) - Colombia</option>
<option value="269">(+269) - Comoros</option>
<option value="682">(+682) - Cook Islands</option>
<option value="506">(+506) - Costa Rica</option>
<option value="225">(+225) - Cote d'Ivoire</option>
<option value="385">(+385) - Croatia</option>
<option value="53">(+53) - Cuba</option>
<option value="599">(+599) - Curacao</option>
<option value="357">(+357) - Cyprus</option>
<option value="420">(+420) - Czech Republic</option>
<option value="243">(+243) - Democratic Republic Of Congo</option>
<option value="45">(+45) - Denmark</option>
<option value="253">(+253) - Djibouti</option>
<option value="1767">(+1-767) - Dominica</option>
<option value="1809">(+1-809) - Dominican Republic</option>
<option value="670">(+670) - East Timor</option>
<option value="593">(+593) - Ecuador</option>
<option value="20">(+20) - Egypt</option>
<option value="503">(+503) - El Salvador</option>
<option value="240">(+240) - Equatorial Guinea</option>
<option value="291">(+291) - Eritrea</option>
<option value="372">(+372) - Estonia</option>
<option value="251">(+251) - Ethiopia</option>
<option value="388">(+388) - European Union</option>
<option value="500">(+500) - Falkland Islands</option>
<option value="298">(+298) - Faroe Islands</option>
<option value="679">(+679) - Fiji</option>
<option value="358">(+358) - Finland</option>
<option value="33">(+33) - France</option>
<option value="241">(+241) - France, Metropolitan</option>
<option value="44">(+44) - French Guiana</option>
<option value="689">(+689) - French Polynesia</option>
<option value="44">(+44) - Gabon</option>
<option value="220">(+220) - Gambia</option>
<option value="594">(+594) - Georgia</option>
<option value="49">(+49) - Germany</option>
<option value="233">(+233) - Ghana</option>
<option value="350">(+350) - Gibraltar</option>
<option value="30">(+30) - Greece</option>
<option value="299">(+299) - Greenland</option>
<option value="995">(+995) - Grenada</option>
<option value="590">(+590) - Guadeloupe</option>
<option value="1671">(+1-671) - Guam</option>
<option value="502">(+502) - Guatemala</option>
<option value="224">(+224) - Guinea</option>
<option value="245">(+245) - Guinea-bissau</option>
<option value="592">(+592) - Guyana</option>
<option value="509">(+509) - Haiti</option>
<option value="504">(+504) - Honduras</option>
<option value="852">(+852) - Hong Kong</option>
<option value="36">(+36) - Hungary</option>
<option value="354">(+354) - Iceland</option>
<option value="91">(+91) - India</option>
<option value="62">(+62) - Indonesia</option>
<option value="98">(+98) - Iran, Islamic Republic Of</option>
<option value="964">(+964) - Iraq</option>
<option value="353">(+353) - Ireland</option>
<option value="44">(+44) - Isle Of Man</option>
<option value="972">(+972) - Israel</option>
<option value="39">(+39) - Italy</option>
<option value="1876">(+1-876) - Jamaica</option>
<option value="81">(+81) - Japan</option>
<option value="44">(+44) - Jersey</option>
<option value="962">(+962) - Jordan</option>
<option value="7">(+7) - Kazakhstan</option>
<option value="254">(+254) - Kenya</option>
<option value="686">(+686) - Kiribati</option>
<option value="850">(+850) - Korea, Democratic People's Republic Of</option>
<option value="82">(+82) - Korea, Republic Of</option>
<option value="965">(+965) - Kuwait</option>
<option value="996">(+996) - Kyrgyzstan</option>
<option value="856">(+856) - Lao People's Democratic Republic</option>
<option value="371">(+371) - Latvia</option>
<option value="961">(+961) - Lebanon</option>
<option value="266">(+266) - Lesotho</option>
<option value="231">(+231) - Liberia</option>
<option value="218">(+218) - Libya</option>
<option value="423">(+423) - Liechtenstein</option>
<option value="370">(+370) - Lithuania</option>
<option value="352">(+352) - Luxembourg</option>
<option value="853">(+853) - Macao</option>
<option value="389">(+389) - Macedonia, The Former Yugoslav Republic Of</option>
<option value="261">(+261) - Madagascar</option>
<option value="265">(+265) - Malawi</option>
<option value="60">(+60) - Malaysia</option>
<option value="960">(+960) - Maldives</option>
<option value="223">(+223) - Mali</option>
<option value="356">(+356) - Malta</option>
<option value="692">(+692) - Marshall Islands</option>
<option value="596">(+596) - Martinique</option>
<option value="222">(+222) - Mauritania</option>
<option value="230">(+230) - Mauritius</option>
<option value="262">(+262) - Mayotte</option>
<option value="52">(+52) - Mexico</option>
<option value="691">(+691) - Micronesia, Federated States Of</option>
<option value="373">(+373) - Moldova</option>
<option value="377">(+377) - Monaco</option>
<option value="976">(+976) - Mongolia</option>
<option value="382">(+382) - Montenegro</option>
<option value="1664">(+1-664) - Montserrat</option>
<option value="212">(+212) - Morocco</option>
<option value="258">(+258) - Mozambique</option>
<option value="95">(+95) - Myanmar</option>
<option value="264">(+264) - Namibia</option>
<option value="674">(+674) - Nauru</option>
<option value="977">(+977) - Nepal</option>
<option value="31">(+31) - Netherlands</option>
<option value="687">(+687) - New Caledonia</option>
<option value="64">(+64) - New Zealand</option>
<option value="505">(+505) - Nicaragua</option>
<option value="227">(+227) - Niger</option>
<option value="234">(+234) - Nigeria</option>
<option value="683">(+683) - Niue</option>
<option value="672">(+672) - Norfolk Island</option>
<option value="1670">(+1-670) - Northern Mariana Islands</option>
<option value="47">(+47) - Norway</option>
<option value="968">(+968) - Oman</option>
<option value="92">(+92) - Pakistan</option>
<option value="680">(+680) - Palau</option>
<option value="970">(+970) - Palestinian Territory, Occupied</option>
<option value="507">(+507) - Panama</option>
<option value="675">(+675) - Papua New Guinea</option>
<option value="595">(+595) - Paraguay</option>
<option value="51">(+51) - Peru</option>
<option value="63">(+63) - Philippines</option>
<option value="48">(+48) - Poland</option>
<option value="351">(+351) - Portugal</option>
<option value="1787">(+1-787) - Puerto Rico</option>
<option value="974">(+974) - Qatar</option>
<option value="242">(+242) - Republic Of Congo</option>
<option value="262">(+262) - Reunion</option>
<option value="40">(+40) - Romania</option>
<option value="7">(+7) - Russian Federation</option>
<option value="250">(+250) - Rwanda</option>
<option value="590">(+590) - Saint Barthélemy</option>
<option value="290">(+290) - Saint Helena, Ascension And Tristan Da Cunha</option>
<option value="1869">(+1-869) - Saint Kitts And Nevis</option>
<option value="1758">(+1-758) - Saint Lucia</option>
<option value="590">(+590) - Saint Martin</option>
<option value="508">(+508) - Saint Pierre And Miquelon</option>
<option value="1784">(+1-784) - Saint Vincent And The Grenadines</option>
<option value="685">(+685) - Samoa</option>
<option value="378">(+378) - San Marino</option>
<option value="239">(+239) - Sao Tome And Principe</option>
<option value="966">(+966) - Saudi Arabia</option>
<option value="221">(+221) - Senegal</option>
<option value="381">(+381) - Serbia</option>
<option value="248">(+248) - Seychelles</option>
<option value="232">(+232) - Sierra Leone</option>
<option value="65">(+65) - Singapore</option>
<option value="1721">(+1-721) - Sint Maarten</option>
<option value="421">(+421) - Slovakia</option>
<option value="386">(+386) - Slovenia</option>
<option value="677">(+677) - Solomon Islands</option>
<option value="252">(+252) - Somalia</option>
<option value="27">(+27) - South Africa</option>
<option value="34">(+34) - Spain</option>
<option value="94">(+94) - Sri Lanka</option>
<option value="249">(+249) - Sudan</option>
<option value="597">(+597) - Suriname</option>
<option value="47">(+47) - Svalbard And Jan Mayen</option>
<option value="268">(+268) - Swaziland</option>
<option value="46">(+46) - Sweden</option>
<option value="41">(+41) - Switzerland</option>
<option value="963">(+963) - Syrian Arab Republic</option>
<option value="886">(+886) - Taiwan, Province Of China</option>
<option value="992">(+992) - Tajikistan</option>
<option value="255">(+255) - Tanzania, United Republic Of</option>
<option value="66">(+66) - Thailand</option>
<option value="228">(+228) - Togo</option>
<option value="690">(+690) - Tokelau</option>
<option value="676">(+676) - Tonga</option>
<option value="1868">(+1-868) - Trinidad And Tobago</option>
<option value="290">(+290) - Tristan de Cunha</option>
<option value="216">(+216) - Tunisia</option>
<option value="90">(+90) - Turkey</option>
<option value="993">(+993) - Turkmenistan</option>
<option value="1649">(+1-649) - Turks And Caicos Islands</option>
<option value="688">(+688) - Tuvalu</option>
<option value="256">(+256) - Uganda</option>
<option value="380">(+380) - Ukraine</option>
<option value="971">(+971) - United Arab Emirates</option>
<option value="1473">(+1-473) - United Kingdom</option>
<option value="1">(+1) - United States</option>
<option value="598">(+598) - Uruguay</option>
<option value="998">(+998) - Uzbekistan</option>
<option value="678">(+678) - Vanuatu</option>
<option value="379">(+379) - Vatican City State</option>
<option value="58">(+58) - Venezuela, Bolivarian Republic Of</option>
<option value="84">(+84) - Viet Nam</option>
<option value="1284">(+1-284) - Virgin Islands (British)</option>
<option value="1340">(+1-340) - Virgin Islands (US)</option>
<option value="681">(+681) - Wallis And Futuna</option>
<option value="212">(+212) - Western Sahara</option>
<option value="967">(+967) - Yemen</option>
<option value="260">(+260) - Zambia</option>
<option value="263">(+263) - Zimbabwe</option>
</select>
<div class="input-group">
<input style="padding-left:32%" name="phone" type="text" id="phone_number" value="" oninput="this.value = this.value.replace(/[^0-9]/g, '');" class="form-control" placeholder="Phone Number" required="">
<span class="input-group-addon"><i class="fa fa-phone"></i></span>
</div>
</div>
</div>
<br>
<div class="row">
<div class="col-md-6">
<b>Gender <font color="red">*</font></b><br>
<select name="gender" type="text" id="gender" value="" class="form-control" required="">
<option value="">Please Select</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
</select>
</div>
<div class="col-md-6">
<b>Address <font color="red">*</font></b><br>
<div class="input-group">
<input name="address" type="text" id="address" value="" class="form-control" placeholder="Address" required="">
<span class="input-group-addon"><i class="fa fa-address-card"></i></span>
</div>
</div>
</div>
<br>
<div class="row">
<div class="col-md-4">
<b>Nationality <font color="red">*</font></b><br>
<select onchange="valState()" name="country" type="text" id="country" value="" class="form-control" required="">
<option value="">Select Country</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antartica">Antartica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Ashmore and Cartier Island">Ashmore and Cartier Island</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="British Virgin Islands">British Virgin Islands</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burma">Burma</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Clipperton Island">Clipperton Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Congo, Republic of the">Congo, Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote d'Ivoire">Cote d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Cyprus">Cyprus</option>
<option value="Czeck Republic">Czeck Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Europa Island">Europa Island</option>
<option value="Falkland Islands (Islas Malvinas)">Falkland Islands (Islas Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern and Antarctic Lands">French Southern and Antarctic Lands</option>
<option value="Gabon">Gabon</option>
<option value="Gambia, The">Gambia, The</option>
<option value="Gaza Strip">Gaza Strip</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Glorioso Islands">Glorioso Islands</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City)">Holy See (Vatican City)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Howland Island">Howland Island</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Ireland, Northern">Ireland, Northern</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Jan Mayen">Jan Mayen</option>
<option value="Japan">Japan</option>
<option value="Jarvis Island">Jarvis Island</option>
<option value="Jersey">Jersey</option>
<option value="Johnston Atoll">Johnston Atoll</option>
<option value="Jordan">Jordan</option>
<option value="Juan de Nova Island">Juan de Nova Island</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, North">Korea, North</option>
<option value="Korea, South">Korea, South</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia, Former Yugoslav Republic of">Macedonia, Former Yugoslav Republic of</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Man, Isle of">Man, Isle of</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia, Federated States of">Micronesia, Federated States of</option>
<option value="Midway Islands">Midway Islands</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="Netherlands Antilles">Netherlands Antilles</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcaim Islands">Pitcaim Islands</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Reunion">Reunion</option>
<option value="Romainia">Romainia</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Helena">Saint Helena</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Scotland">Scotland</option>
<option value="Senegal">Senegal</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and South Sandwich Islands">South Georgia and South Sandwich Islands</option>
<option value="Spain">Spain</option>
<option value="Spratly Islands">Spratly Islands</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard">Svalbard</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Tobago">Tobago</option>
<option value="Toga">Toga</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad">Trinidad</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="Uruguay">Uruguay</option>
<option value="USA">USA</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands">Virgin Islands</option>
<option value="Wales">Wales</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="West Bank">West Bank</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Yugoslavia">Yugoslavia</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
</div>
<div class="col-md-4">
<b>State <font color="red">*</font></b><br>
<select name="state" type="text" id="state" value="" onchange="$('#aud_state').html($('#state').html())" class="form-control" disabled="" required=""></select>
</div>
<div class="col-md-4">
<b>City <font color="red">*</font></b><br>
<div class="input-group">
<input name="city" type="text" id="city" value="" class="form-control" placeholder="City" required="">
<span class="input-group-addon"><i class="fa fa-building"></i></span>
</div>
</div>
</div>
<br>
<div class="row">
<div class="col-md-6">
<b>Date of Birth <font color="red">*</font></b><br>
<div class="input-group">
<input name="dob" type="date" id="dob" value="" class="form-control" placeholder="" required="">
<span class="input-group-addon"><i class="fa fa-calendar"></i></span>
</div>
</div>
<div class="col-md-6">
<b>Occupation <font color="red">*</font></b><br>
<select name="occupation" type="text" id="occupation" value="" class="form-control" required="">
<option value="">Please Select</option>
<option value="Student">Student</option>
<option value="Self employed">Self employed</option>
<option value="Others">Others</option>
</select>
</div>
</div>
</div>
<div class="row">
<div class="col-md-8 col-md-offset-2">
<br>
<input type="checkbox" name="agree" id="agree" required=""> I hereby attest that all information provided by me in this form is correct and I will be persecuted by <!--?php echo $name;?--> if any is confirmed false.
<!--?php if($type2 == '1'){?--><b>Also Note that the Mr & Miss Regal Nigeria Reg Fee is a None Refundable Fee.</b><!--?php } ?-->
</div>
</div>
<div class="row">
<br>
<br>
<div class="col-md-6 col-md-offset-3">
<input type="hidden" name="title" value="Mr & Miss Regal Nigeria">
<button class="btn btn-success" type="submit" id="formSub" style="display:<?php echo $bank;?>">Submit Form</button>
</div>
</div>
</form>POST
<form method="POST" id="frm-subscribe" class="frm-subscribe has-validation-callback" onsubmit="return sub();">
<input type="hidden" value="subscribeNewsletter" name="action" id="action">
<div class="sections section-subcribe">
<div class="container">
<h2>Subscribe to our newsletter</h2>
<div class="subscribe-footer">
<div class="row border" style="padding:15px">
<div style="padding-right: 0px; padding-left: 0px;" class="col-md-4 col-sm-4 border col-md-offset-3 col-sm-offset-3 col-xs-12">
<input placeholder="E-mail" style="width:100%;" required="required" class="email" type="text" value="" name="subscriber_email" id="subscriber_email">
</div>
<div style="padding-right: 0px; padding-left: 0px;" class="col-md-2 col-sm-2 border col-xs-12">
<button name="subscriber_submit" class="green-button rounded" style="width:100%"> Subscribe </button>
</div>
</div>
</div>
</div>
<img src="../images/divider.png" class="footer-divider">
</div> <!--section-browse-resto-->
</form>Text Content
Home About Developer HOW IT WORKS 1. Pay the sum of NGN5,000 to Opay 9113643719 (Mr & Miss Regal Nigeria) 2. Fill the form and provide evidence of payment on Whatsapp 3. Kindly note that registration remains invalid until payment is made First Name * Last Name * Email * Phone Number * (+93) - Afghanistan(+355) - Albania(+213) - Algeria(+1-684) - American Samoa(+376) - Andorra(+244) - Angola(+1-264) - Anguilla(+672) - Antarctica(+1-268) - Antigua And Barbuda(+54) - Argentina(+374) - Armenia(+297) - Aruba(+247) - Ascension Island(+61) - Australia(+43) - Austria(+994) - Azerbaijan(+1-242) - Bahamas(+973) - Bahrain(+880) - Bangladesh(+1-246) - Barbados(+375) - Belarus(+32) - Belgium(+501) - Belize(+229) - Benin(+1-441) - Bermuda(+975) - Bhutan(+591) - Bolivia, Plurinational State Of(+599) - Bonaire, Saint Eustatius And Saba(+387) - Bosnia & Herzegovina(+267) - Botswana(+55) - Brazil(+246) - British Indian Ocean Territory(+673) - Brunei Darussalam(+359) - Bulgaria(+226) - Burkina Faso(+257) - Burundi(+855) - Cambodia(+237) - Cameroon(+1) - Canada(+238) - Cape Verde(+1-345) - Cayman Islands(+236) - Central African Republic(+235) - Chad(+56) - Chile(+86) - China(+61) - Christmas Island(+61) - Cocos (Keeling) Islands(+57) - Colombia(+269) - Comoros(+682) - Cook Islands(+506) - Costa Rica(+225) - Cote d'Ivoire(+385) - Croatia(+53) - Cuba(+599) - Curacao(+357) - Cyprus(+420) - Czech Republic(+243) - Democratic Republic Of Congo(+45) - Denmark(+253) - Djibouti(+1-767) - Dominica(+1-809) - Dominican Republic(+670) - East Timor(+593) - Ecuador(+20) - Egypt(+503) - El Salvador(+240) - Equatorial Guinea(+291) - Eritrea(+372) - Estonia(+251) - Ethiopia(+388) - European Union(+500) - Falkland Islands(+298) - Faroe Islands(+679) - Fiji(+358) - Finland(+33) - France(+241) - France, Metropolitan(+44) - French Guiana(+689) - French Polynesia(+44) - Gabon(+220) - Gambia(+594) - Georgia(+49) - Germany(+233) - Ghana(+350) - Gibraltar(+30) - Greece(+299) - Greenland(+995) - Grenada(+590) - Guadeloupe(+1-671) - Guam(+502) - Guatemala(+224) - Guinea(+245) - Guinea-bissau(+592) - Guyana(+509) - Haiti(+504) - Honduras(+852) - Hong Kong(+36) - Hungary(+354) - Iceland(+91) - India(+62) - Indonesia(+98) - Iran, Islamic Republic Of(+964) - Iraq(+353) - Ireland(+44) - Isle Of Man(+972) - Israel(+39) - Italy(+1-876) - Jamaica(+81) - Japan(+44) - Jersey(+962) - Jordan(+7) - Kazakhstan(+254) - Kenya(+686) - Kiribati(+850) - Korea, Democratic People's Republic Of(+82) - Korea, Republic Of(+965) - Kuwait(+996) - Kyrgyzstan(+856) - Lao People's Democratic Republic(+371) - Latvia(+961) - Lebanon(+266) - Lesotho(+231) - Liberia(+218) - Libya(+423) - Liechtenstein(+370) - Lithuania(+352) - Luxembourg(+853) - Macao(+389) - Macedonia, The Former Yugoslav Republic Of(+261) - Madagascar(+265) - Malawi(+60) - Malaysia(+960) - Maldives(+223) - Mali(+356) - Malta(+692) - Marshall Islands(+596) - Martinique(+222) - Mauritania(+230) - Mauritius(+262) - Mayotte(+52) - Mexico(+691) - Micronesia, Federated States Of(+373) - Moldova(+377) - Monaco(+976) - Mongolia(+382) - Montenegro(+1-664) - Montserrat(+212) - Morocco(+258) - Mozambique(+95) - Myanmar(+264) - Namibia(+674) - Nauru(+977) - Nepal(+31) - Netherlands(+687) - New Caledonia(+64) - New Zealand(+505) - Nicaragua(+227) - Niger(+234) - Nigeria(+683) - Niue(+672) - Norfolk Island(+1-670) - Northern Mariana Islands(+47) - Norway(+968) - Oman(+92) - Pakistan(+680) - Palau(+970) - Palestinian Territory, Occupied(+507) - Panama(+675) - Papua New Guinea(+595) - Paraguay(+51) - Peru(+63) - Philippines(+48) - Poland(+351) - Portugal(+1-787) - Puerto Rico(+974) - Qatar(+242) - Republic Of Congo(+262) - Reunion(+40) - Romania(+7) - Russian Federation(+250) - Rwanda(+590) - Saint Barthélemy(+290) - Saint Helena, Ascension And Tristan Da Cunha(+1-869) - Saint Kitts And Nevis(+1-758) - Saint Lucia(+590) - Saint Martin(+508) - Saint Pierre And Miquelon(+1-784) - Saint Vincent And The Grenadines(+685) - Samoa(+378) - San Marino(+239) - Sao Tome And Principe(+966) - Saudi Arabia(+221) - Senegal(+381) - Serbia(+248) - Seychelles(+232) - Sierra Leone(+65) - Singapore(+1-721) - Sint Maarten(+421) - Slovakia(+386) - Slovenia(+677) - Solomon Islands(+252) - Somalia(+27) - South Africa(+34) - Spain(+94) - Sri Lanka(+249) - Sudan(+597) - Suriname(+47) - Svalbard And Jan Mayen(+268) - Swaziland(+46) - Sweden(+41) - Switzerland(+963) - Syrian Arab Republic(+886) - Taiwan, Province Of China(+992) - Tajikistan(+255) - Tanzania, United Republic Of(+66) - Thailand(+228) - Togo(+690) - Tokelau(+676) - Tonga(+1-868) - Trinidad And Tobago(+290) - Tristan de Cunha(+216) - Tunisia(+90) - Turkey(+993) - Turkmenistan(+1-649) - Turks And Caicos Islands(+688) - Tuvalu(+256) - Uganda(+380) - Ukraine(+971) - United Arab Emirates(+1-473) - United Kingdom(+1) - United States(+598) - Uruguay(+998) - Uzbekistan(+678) - Vanuatu(+379) - Vatican City State(+58) - Venezuela, Bolivarian Republic Of(+84) - Viet Nam(+1-284) - Virgin Islands (British)(+1-340) - Virgin Islands (US)(+681) - Wallis And Futuna(+212) - Western Sahara(+967) - Yemen(+260) - Zambia(+263) - Zimbabwe Gender * Please Select Male Female Address * Nationality * Select CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAngolaAnguillaAntarticaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzeck RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City)HondurasHong KongHowland IslandHungaryIcelandIndiaIndonesiaIranIraqIrelandIreland, NorthernIsraelItalyJamaicaJan MayenJapanJarvis IslandJerseyJohnston AtollJordanJuan de Nova IslandKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMan, Isle ofMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcaim IslandsPolandPortugalPuerto RicoQatarReunionRomainiaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaScotlandSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South Sandwich IslandsSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTobagoTogaTokelauTongaTrinidadTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUSAUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWalesWallis and FutunaWest BankWestern SaharaYemenYugoslaviaZambiaZimbabwe State * City * Date of Birth * Occupation * Please Select Student Self employed Others I hereby attest that all information provided by me in this form is correct and I will be persecuted by if any is confirmed false. Also Note that the Mr & Miss Regal Nigeria Reg Fee is a None Refundable Fee. Submit Form SUBSCRIBE TO OUR NEWSLETTER Subscribe Copyright 2020 | Technology by CALYs Global Concept